Fill and Sign the Mississippi Commitment Form

IN THE CHANCERY COURT OF       COUNTY, MISSISSIPPI       PLAINTIFF VS. CIVIL ACTION NO.             DEFENDANT COMPLAINT FOR EMERGENCY COMMITMENT OF A CHEMICALLY DEPENDENT PERSON FOR TREATMENT COMES NOW,       , Plaintiff, and files his/her Complaint for Emergency Commitment of a Chemically Dependent Person for Treatment against       , and in support hereof would show unto the Court the following, to-wit: 1. Plaintiff, the Defendant's husband/wife is an adult resident citizen of       County, Mississippi, residing at       and Defendant is an adult resident citizen of       County, Mississippi, presently residing with Plaintiff. 2. Defendant is a chemically dependent person, i.e., he/she is powerless over controlled substances,       , specifically       , and his life has thereby become unmanageable. Defendant indicates suicidal tendencies, is hostile, and is dehydrated to the extent that he/she had to be committed to a hospital due to alcoholism. He/She is suffering from withdrawal, refuses to ingest very little sustenance by the way of nutrition. 3. The Defendant's mental and physical health, his/her continued family life and his/her position in the community are dependent on his/her treatment at a chemical dependency unit. 4. The Plaintiff has selected a particular treatment facility located in the State of Mississippi, which has been approved by the Department of Mental Health, division of alcohol and drug abuse, and is willing for the Defendant to go to       and has been pre-approved by said facility by       , agent for said facility. The Defendant is presently a voluntary resident of the facility but has indicated his/her desire to leave. Plaintiff is fearful that without an Order, Defendant will leave the facility and lose valuable treatment and be a danger to himself and the public. 5. The Defendant has health insurance and the Plaintiff is able to provide for the payment of any treatment for Defendant at said facility. 6. The treatment facility, at this juncture, has approved the admission of the Defendant, and Defendant is a current resident there. 7. The Plaintiff suggests that the Defendant be ordered to remain and committed for a period of not more that       (       ) month(s) or until the institution determines that his/her treatment is complete, whichever is earlier. 8. Defendant is under the influence of mood altering chemicals, i.e.,       and       , to the extent that if he/she is served process he/she will, in all likelihood, flee the jurisdiction of the Court or physically harm himself or others. Plaintiff requests that the Court set the matter for hearing not more that five (5) days, excluding Saturdays, Sundays and legal holidays from the filing of the Complaint, and order the Defendant committed and confined to said treatment facility, without notice, until the hearing. 9. The Sheriffs of       and       County, or any other law enforcement officer, should be directed to transport Defendant to said facility. In the event Defendant leaves the facility against the advise of the Medical Director, and without further order of this Court, the Sheriff, or any other law enforcement officer, should be directed to pick up and return defendant to said facility. WHEREFORE, PREMISES CONSIDERED, Plaintiff prays that the Court set this matter for hearing not more that five (5) days, excluding Saturdays, Sundays and legal holidays, from the filing of the Complaint, and order the Defendant committed and confined and to remain, without notice, pending hearing of this matter, to       ,       , MS in this facility's chemical dependency unit. Plaintiff further prays that the Sheriffs of       and       County, or any other law enforcement officer, be directed to transport the Defendant to said treatment facility, and if Defendant leaves the facility against the advice of the medical director, and without further order of this Court, said Sheriff or any other law enforcement officer should be directed to pick up and return Defendant to said facility. Upon final hearing, Plaintiff prays that Defendant be committed to said treatment facility for not more that two (2) months, and an outpatient for not more that six months, subject to institutional earlier release. Plaintiff prays for such other and general relief to which he may be entitled in the premises. Respectfully submitted, _______________________________________       Attorney for       STATE OF MISSISSIPPI COUNTY OF       PERSONALLY appeared before me, the undersigned authority, in and for the county and state aforesaid, the within named,       . To, being by me first duly sworn, on his oath, who state that the matters, facts, things and averments set forth, contained and alleged in the above and foregoing are true and correct as therein stated. __________________________________       SWORN TO AND SUBSCRIBED before me, this the       day of       , 20       . _________________________________ NOTARY PUBLIC My Commission Expires: _______________________ ____________________________       ATTORNEY FOR PLAINTIFF